Service Charters Establishment of community forums at sub-district

28 Implementation of the school-based management program in Bener Meriah was supported by many different stakeholders, including: a. District Education Office and District Religious Affairs Office. As policy makers, they develop policies and provide inputs on program implementation. They also monitor and evaluate the program. b. Regional facilitators provide training and mentoring for schools. c. Bener Meriah Education Concern Forum. This community forum advocates for local governments and schools to build the capacity of both the service providers and users so that they could implement the public oriented school-based management. d. Teachers and school principals strengthen their relationships with school committees and community members. They also work together with school committees to conduct complaint surveys and fulfilled service charters. e. Students are one of the complaint survey respondent groups. They describe the problems they faced at school. f. School committees are the schools’ partners in implementing school-based management. They encourage community members to participate in school programs. g. Local media help the schools communicate their programs, problems and improvements to the public. 29 Community members work together to make a garden as a response to complaint survey results. Results and Impact Implementation of the complaint survey as a component of school-based management in Bener Meriah brought concrete results and impact. The survey has strengthened partnerships between schools and community members, and has clarified that both are working together to achieve the same goal: better education services. Improved school transparency and accountability By implementing the complaint survey, Bener Meriah’s schools demonstrated their good will to improve, and by making their financial reports, work plans, and complaint indexes publicly available for public, parents and community members can use the documents to oversee the schools’ quality. Increased public participation With increased public participation, schools in Bener Meriah can address problems related to school facilities – a problem that many schools cannot solve themselves due to lack of resources. The school committees can assist schools to repair damaged classrooms and toilets and to build fences and school gardens. 30 Improved school responsiveness The public service team and the complaint survey team at schools were more responsive to public complaints. They discussed the people’s feedback in regular meetings. These good results have brought positive impacts to education services in Bener Meriah. People now trust schools and teachers more than before, because they can observe that the schools are trying to be more transparent and accountable. Furthermore, community members are willing to help schools address problems, and to participate in school programs. In other words, with public participation, the schools in Bener Meriah have become a model schools, implementing genuine public service-oriented school-based management. Monitoring and Evaluation Implementation of school-based management in Bener Meriah is evaluated by school supervisors on behalf of the District Education Office. After conducting field visits, the supervisors discuss their findings with the District Education Office, schools, and other stakeholders. In addition, the Bener Meriah Education Concern Forum holds quarterly meetings to discuss t he schools’ progresses in fulfilling their service charters. Besides external evaluation, school principals are responsible for internal evaluation. They evaluate the school’s programs with teachers and school committee members. 31 Sustainability The District Education Office has integrated the school-based management program, particularly complaint survey at schools, into its work plan and has allocated funds to provide training for schools beyond the original 20 partner schools. The regional facilitators who assisted schools in implementing school based management are invaluable resources. With their experience and expertise, they can be recruited by schools and the local government to assist replication and to support sustainability. The complaint handling mechanisms developed by the schools will help sustain the program. Using this procedure, schools and community members can identify problems and work together to seek out solutions. Strong partnerships and open communication between schools and community members improves people’s trust and increases participation in school programs. Community forums such as the Bener Meriah Education Concern Forum greatly help program sustainability. They provide strong channels for community members to support their local governments and schools to improve education services. Lessons Learned and Recommendations 1. Initially, it was hard to convince schools to be transparent and accountable. They had believed that people would demand more from the schools when they knew about the schools’ plans and reports. To address this issue, the 32 schools were exposed to real examples of the benefits of public participation. The examples came from other schools that had successfully improved their services thanks to increased community support. 2. The program implementers’ capacity to understand the program was varied. School principals, teachers, and school committee members had not been able to implement the school-based management program optimally since they were not exposed to adequate examples. Therefore, regional facilitators had to be creative when assisting program implementers so that everyone could understand and play their roles better. 3. Many community members believed that education was the sole responsibility of government. Although some people did have concerns about education services, they felt that they could not raise their concerns as there was no forum to do so. To address this problem, the program encouraged community members to establish forums at district and sub- district level so that they could discuss the educations issues regularly and seek for the solutions. 4. Complaint handling mechanisms were initially hard to implement since they were a new concept for many people in Bener Meriah. Therefore, complaint handling mechanisms were introduced only after careful preparation. Another challenge with regards with the complaint survey was convincing parents, students, and community members to take part in the survey. Therefore, the complaint survey team had to use efficient and creative approaches to convince the respondents. Behaviour change activities 33 should be conducted first before beginning the complaint handling introduction. 5. Without channels to pass on complaints, the public will not participate. Once methods exist, such as community forums, community members will feel more comfortable in putting forward their concerns and suggestions, and are more likely to actively take part in efforts to improve education services. Contact Person Jailani, S.Pd Head of Program Department Bener Meriah District Education Office Jl. Seurule Kayu, Kompleks Perkantoran Bener Meriah, Aceh Telp: 085260663548 Email: kabid.programbmgmail.com 34 Improving ante-natal care through service SOPs and control cards in Bengkayang, West Kalimantan Background One of the biggest challenges facing Indonesia in its attempt to meet its maternal health targets for the Millennium Development Goals MDGs is that health care is not even or standardized throughout the archipelago. Health services are particularly below standard in remote areas far from major cities. Puskesmas Sungai Raya Kepulauan, a small puskesmas community health center in Bengkayang district, West Kalimantan Province, serves around 400 pregnant women every year despite limited facilities and staff. The puskesmas and its village-level birthing clinics have just one ambulance between them, even though their catchment area covers both the mainland and a large number of islands and river-side communities. Puskesmas Sungai Raya Kepulauan has one doctor and 12 midwives. Twenty traditional birth attendants TBAs are also active in the sub-district. The puskesmas itself does not have a delivery room, so women must give birth at the village- level birthing clinics closer to their homes. Despite its limitations, Puskesmas Sungai Raya Kepulauan has committed to providing a high standard of maternal and child 35 healthcare. In 2012, the center’s doctor and midwives assisted 338 births at facilities or at homes, while TBAs assisted 29 births. No maternal deaths were recorded, but there were two still-births and 12 neonatal deaths. As with other areas in Indonesia, the ante-natal services provided by Puskesmas Sungai Raya Kepulauan vary from facility to facility. No standards are followed, so the quality varies significantly. To overcome this challenge and to standardize ante-natal care, Kinerja assisted the puskesmas to develop and implement standard operating procedures for ante-natal care SOP ANC. The SOP focused less on the details of medical procedures and more on the manner of services required to be given, as it was assumed that all medical staff have been trained in carrying out the required tasks. The staff of Puskesmas Sungai Raya Kepulauan. 36 Program Innovation Public service provision, including health service provision, must be able to be relied upon. One way of ensuring consistency and reliability is to implement standard operating procedures SOPs. SOPs are documents with written instructions on how to carry out an activity, when to carry it out, where to do so, and who is responsible for doing so. By standardizing a process in this way, SOPs ensure that the same tasks will always be carried out in the same way, even if they are performed by different people, at different times, and in different places. This means that activities should always meet the same standard. SOPs are very useful tools for organizational activities that are routine or occur frequently. The consistent implementation of SOPs means that comprehensive guidelines for all activities exist, and that there is no reason for deviation. This makes organizations more accountable and reliable, and there is less chance of mistakes being made – something that is particularly crucial in health care. SOPs act as guides for health workers. They are based on medical and scientific knowledge, and are developed in line with national standards for health care. They must be mandatory with regards to implementation. SOPs also assist with monitoring and evaluation, as they provide a benchmark for what should be done. SOPs are mandated by the Indonesian government through Law no. 252009 on Public Service Delivery. All public service providers are required to develop service delivery standards 37 that are non-discriminatory, respect diversity, and prioritize community consensus. The service SOPs that Kinerja supported the development of are similar to medical SOPs, but instead of providing information on medical procedures, they guide workers on service provision and administrative processes. Kinerja assisted Puskesmas Sungai Raya Kepulauan by developing a number of service SOPs relating to ante-natal care. They include: - Service standards for ante-natal care ten services, known as ‘10T’ in Indonesian, which include measuring the moth er’s nutritional status, measuring uterine height, measuring blood pressure, measuring iron levels, providing iron tablets, and vaccinating for tetanus toxoid - Service flowchart for ante-natal care indicating where a patient should go and in what order, e.g. midwife first, then laboratory, then pharmacy - Referral mechanism for obstetric and neonatal emergencies - Service fee list - Waiting time standards. The puskesmas also made a ‘control card’ that serves as a monitoring tool to analyze whether staff are following the ante- natal care procedures. The control cards are made up of three sections: the first is a list of the ten services a woman should receive during ante-natal care; the second is a box for feedback; and the third contains information on nutrition for mothers and babies, safe delivery, and immediate and exclusive breastfeeding. 38 Half the control card is taken home, while half is put into the suggestion box for follow-up by the puskesmas. All SOPs were developed jointly by administrative and medical staff at the puskesmas, and were socialized to all staff after being signed by the head of the center. In order to ensure compliancy and to build patients’ knowledge on their rights to healthcare, the puskesmas displayed the SOPs on the walls and doors of both the waiting room and the ante-natal care room. The control cards are also given to all women visiting for ante-natal care upon registration with the front desk. Implementation Process 1. Mapping existing SOPs and service standards. Before developing new SOPs – whether medical or service SOPs – existing SOPs and service standards at the puskesmas and District Health Office DHO need to be mapped and analyzed. The staff of Puskesmas Sungai Raya Kepulauan compiled all of their SOPs and standards, and evaluated whether they met national standards and whether they were properly implemented. The control card used for measuring ante- natal care services introduced at Puskesmas Sungai Raya Kepulauan. 39 2. Mapping SOPs and service standards that should be implemented. The puskesmas staff and the local multi- stakeholder forum MSF – a type of community forum for public service oversight – came together to discuss the services delivered by the puskesmas. They identified which services did not yet have SOPs or did not have SOPs in line with national standards. One of these was ante-natal care – although the puskesmas had already developed an SOP for ANC, it did not state the amount of time procedures should take nor the costs for such services. 3. Drafting of new SOPs. All new SOPs were developed in a participatory and transparent fashion. Unlike the traditional top-down method where the head of the puskesmas or the head midwife drafts the SOPs, at Puskesmas Sungai Raya Kepulauan, all staff and MSF members were invited to take part. This ensured that all stakeholders felt involved and listened to, and that all could fully commit to implementing the new SOPs. 4. Socialization of new SOPs. After being drafted and agreed upon, all SOPs were socialized to all staff and were trialed before being officially implemented. It is vital that all staff have a strong understanding of what each SOP contains and what services it guarantees to give patients. Without proper socialization, staff may ignore the new SOPs and not implement them. 5. Transparent publishing of SOPs. All new SOPs were printed and displayed on the walls and doors of the puskesmas. This transparency increases the trust of the community towards health workers and improves the 40 quality of the services they receive for two reasons – one, because health workers are constantly reminded of what they should do, and two, because patients are aware of what they should receive. The ’ten steps’ of ante-natal care SOP is displayed in the ANC Room and on its door, along with the service flowchart, waiting times, and referral mechanism. The list of service costs is displayed in the waiting room. Displaying these SOPs in these locations gives pregnant women the greatest amount of time to read and understand the types of ante-natal care they should receive at the puskesmas. 6. Implementation, display, and socialization of SOPs to all public health facilities in the sub-district. After trialing and implementing the new SOPs at the puskesmas, the staff ensured that all other public health facilities under their management also implemented and displayed the SOPs. This included at village-level birthing clinics polindes and poskesdes and monthly mother-and-baby sessions at the integrated health posts posyandu. This was done to ensure that ante-natal care quality did not vary from one facility to another. The list of fees for services and the new referral mechanism were also displayed at all facilities to make sure that the information reached all residents. 7. Routine re-socialization of SOPs. To ensure compliance with SOPs, routine re-socialization to staff is necessary. The staff should then continue this by reminding the community of the standards of services they should receive. This is important to make sure that SOPs are not forgotten or ignored. 41 8. Development of ANC control card for monitoring SOP compliance. Puskesmas Sungai Raya Kepulauan was the first puskesmas to implement Kinerja’s ANC control card. The card includes information for patients on the ANC services they should receive, offers a section for feedback, and provides information on maternal health, nutrition, and breastfeeding. The cards are printed on ordinary white A4 paper and cut to make two cards per sheet. At Puskesmas Sungai Raya Kepulauan, 500 cards are enough for all pregnant women for one year. Results and impact The biggest impact of implementing SOPs and the control card for ante-natal care at Puskesmas Sungai Raya Kepulauan was the standardization of services across all public health facilities in the sub-district. Now, pregnant women can receive the same quality of service whether she goes to the puskesmas or to a village-level birthing clinic, because all have implemented clear SOPs on ante-natal care. Since introducing service SOPs, the number of patient complaints regarding costs and waiting times have dramatically reduced. The staff see this as a result of displaying standard fees and waiting times in the waiting room. The other impact has been an increase in the number of women coming to facilities for ante-natal care and childbirth. A marked increase occurred between 2012, when service SOPs were introduced, and 2013. The staff at the puskesmas explain this as a result of women now knowing more about the services they should receive, which has resulted in higher levels 42 of trust. The clarity with which services are outlined in the SOPs means that women feel more comfortable in coming to the puskesmas and other facilities, as they know exactly what will happen, who will perform it, how much it will cost, and when they can receive the service. Related to the increase in facility-based births is that immediate breastfeeding rates have more than doubled between 2012 and 2013. This is because all midwives are now required to perform immediate breastfeeding for births both at facilities and at homes. Midwives also assist in performing the procedure when called by TBAs or families to assist with deliveries, even if they arrive too late to assist the birth itself. This has also had a small impact 13 increase on exclusive breastfeeding rates. Neonatal deaths have also decreased by more than 40. Maternal health statistics for Sungai Raya Kepulauan sub- district, Bengkayang 2012-2013 Births assisted by trained medical workers Births assisted by TBAs Immediate breast- feeding Exclusive breast- feeding Neonatal deaths 2012 338 29 208 77 14 2013 418 24 451 87 8 Monitoring and evaluation Although Puskesmas Sungai Raya Kepulauan began implementing its SOPs in late 2012 and early 2013, it did not develop the ANC control card until 2014 when the staff realized they needed a better method of monitoring compliance. 43 The control card enables the puskesmas to explore what services are being provide, and if they are not, why not. All ANC patients return half of their control cards to the puskesmas after their check-ups; the patients keep the other half. As the control cards list the ten services all pregnant women are supposed to receive, the staff can examine the services one by one. For example, if multiple cards indicate that the patient did not receive iron tablets which all patients should receive, the staff will investigate the issue and find out why: was it because the women did not want the tablets? Was it because there are no tablets in stock? Was it because the midwife did not offer them? After identifying the problem, the staff can then work to find a solution. Challenges At the beginning, many staff at Puskesmas Sungai Raya Kepulauan lacked knowledge of SOPs. Not only were they not aware of how to develop medical and service SOPs, staff did also not know about the importance of having SOPs and standardized services. This meant that Kinerja spent some months raising the knowledge and understanding of puskesmas staff first, before beginning to examine existing SOPs and drafting new ones. Another significant challenge that became obvious during the assistance period was that there was confusion over the different between medical SOPs and service SOPs. Medical SOPs contain the steps required to carry out medical procedures on patients, whereas service SOPs cover how the non-medical aspects of services are implemented. For example, 44 an SOP on childbirth is a medical SOP, while an SOP on complaint handling is a service SOP. This issue emerged a number of times, especially when new staff began working at the puskesmas and had never encountered service SOPs before. Transparency was also an issue. Many SOPs, both medical and service, had been developed over the years. However, few were displayed for staff andor public consumption – the vast majority were simply stored in drawers or cupboards and never looked at. This meant that SOPs largely went unimplemented and unfollowed, and that staff did not understand why SOPs should be displayed on walls or doors. This was especially the case amongst medical staff, some of whom believed that SOPs were private documents that should not be available to the community. A service SOP for ante-natal care on display on the door of the MCH room at Puskesmas Sungai Raya Kepulauan. 45 Sustainability The implementation of SOPs on ante-natal care will be sustainable at Puskesmas Sungai Raya Kepulauan if they are regularly monitored. Without monitoring, they are likely to disappear off the walls and end up in drawers and cupboards once more, unimplemented. The display of and compliance towards SOPs should be monitored not just by the head of the puskesmas and the head midwife, but also by the community. All people are entitled to have oversight over implementation. If staff or community members see a member of staff not following an SOP, they should report it to the head of the puskesmas or the head midwife to ensure it does not happen again. This means that SOPs should be regarded as living documents that can be altered based on feedback, monitoring and evaluation, and new developments in technology and policies. Cost-wise, SOPs do not require any finance upkeep. Control cards can be printed andor photo-copied once a year for a small fee. The DHO of Bengkayang has stated that they will replicate SOPs for ANC to all puskesmas in the district in 2015. Lessons learned and recommendations Puskesmas Sungai Raya Kepulauan is now regarded by the Bengkayang DHO as one of the district’s most innovative puskesmas in terms of maternal and child health. Puskesmas Sungai Raya Kepulauan’s experience proves that service SOPs on ante-natal care can have a significant and 46 immediate effect on the quality of care. By following standard procedures and meeting national standards, the puskesmas and its staff can show patients that they are providing appropriate care that is as good as at any other puskesmas elsewhere in the country. Service SOPs are most effective when they are developed and implemented in a participatory and transparent manner. Community representatives should be involved in the design and monitoring processes, as should all puskesmas staff. Service SOPs should also be displayed in public on the walls and doors of health facilities, to ensure compliance from staff and to build public awareness of the rights to quality health care. Both medical and service SOPs should ideally be standardized across the country, with allowances for local variations and add-on services such as HIV testing and urine testing for puskesmas with appropriate laboratory facilities, and ultrasounds for facilities with USG machines. Doing so will reduce the chance of non-compliance to standard care procedures, and will ensure that all mothers and babies receive the same services. Contact details Mahlil Ruby Former Health Specialist, Kinerja USAID drmahlilhotmail.com Kate Walton Knowledge Management and Training Specialist, Kinerja USAID kwaltonkinerja.or.id katewalton.augmail.com 47 Improving health service quality through service charters Background Probolinggo District in East Java covers a population of more than one million people living across a large area. This means there is a high demand for healthcare. The District has 33 puskesmas, including 19 which provide in-patient facilities. One of these is Puskesmas Sumberasih. Despite being one of the best puskesmas in the district, Puskesmas Sumberasih still witnesses multiple maternal and neonatal deaths every year. Before the puskesmas began working with Kinerja, field data revealed numerous issues: partnerships between midwives and traditional birth attendants did not run smoothly; standard operating procedures SOPs on pregnancy, delivery and neonatal care had not been developed; no complaint surveys had ever been carried out; waiting times averaged over 30 minutes; formula milk was commonly promoted at health facilities; no staff member was tasked with overseeing the daily running of healthcare; and there was no public joint commitment from the management and the staff to provide the best health services possible. Puskesmas Sumberasih serves around 1,000 pregnant women every year. This led to the management agreeing to work with Kinerja to improve their maternal and child health MCH services to ensure that mothers and babies made it through pregnancy and delivery safely. 48 Program Innovation In order to improve the quality of its MCH services, Puskesmas Sumberasih decided to focus on improving its management. This was because the medical care provided by the puskesmas was deemed to already be sufficient, with the problems experienced at the facility originating more from administrative and operational processes. The puskesmas undertook the following activities: 1. Developing SOPs for both medical and service procedures relating to MCH. 2. Implementing a complaint survey to show that the puskesmas was open to changing and receiving feedback from patients and the broader community. 3. Informal relationship building between traditional birth attendants and puskesmas medical staff, led by the head of the puskesmas. 4. Introducing a ban on formula milk in the sub-district’s health facilities and at private midwifery clinics, and providing breastfeeding equipment such as breastmilk pumps and fridges for storage at the puskesmas. 5. Establishment of a Manager on Duty position to oversee the daily provision of services, including ensuring that staff arrive and leave on time, that staff are providing services in line with SOPs, and that patients are able to pass on any complaints or suggestions. 6. Provision of nutrient-rich plants to pregnant mothers after attending ante-natal check-ups, particularly after the first and second trimester check-ups. Mothers were given daun katuk and daun kelor plants, which are both highly nutritious and promote breastfeeding. 49 7. Carrying out a complaint survey and developing a service charter containing agreed improvements that need to be made, along with technical recommendations for the District Health Office DHO. For Puskesmas Sumberasih, one of the most meaningful activities they conducted was the complaint survey and its resulting service charter. All 61 of Kinerja’s partner puskesmas throughout Indonesia, including Puskesmas Sumberasih, were required to develop service charters as a way of involving the community in improving service quality. Service charters were developed following a complaint survey, in which a structured questionnaire was used to gather complaints and feedback from service users. The survey was carried out by members of the local sub-district multi-stakeholder forum MSF, which is made up of community members. The complaints fielded during the survey were ranked in a complaint index by the quantity of responses to certain issues. The complaints were then discussed in a number of FGDs, and solutions were put forward by both community members and puskesmas staff. Once solutions were agreed upon, the puskesmas drafted a service charter which outline the problems that could be solved internally by the puskesmas itself. For external problems, which required the assistance of the local government, a list of technical recommendations was given to the DHO. Both were signed by the head of the puskesmas. The service charter was printed as a standing banner and displayed in the puskesmas waiting room so that it was visible to all patients. 50 Service charters are a useful way to increase meaningful civic engagement in public service delivery. They help to ensure that services are accountable and transparent, and that providers are responsive to service users’ needs. Puskesmas Sumberasih worked on fulfilling its service charter promises over the 12 months following its development; the banner was displayed throughout this entire period. Implementation Process 1. Initial meeting between puskesmas and Kinerja’s implementing organization , the Children’s Protection Organization Lembaga Perlindungan Anak – LPA. LPA met with the head of Puskesmas S umberasih to discuss both Kinerja’s and the puskesmas’ aims and hopes. The head of Puskesmas Sumberasih stated that community members have the right to participate in public service improvement efforts, and that he was interested in exploring how community complaints could help. 2. Changing ideas of what complaints mean. The head of Puskesmas Sumberasih knew his staff were reluctant to deal with community complaints, as they felt as though they were simply being criticized. He worked hard to convince his staff that complaints were actually a source of information that could help them improve their services, and that one way of accessing this was through a complaint survey. 3. Establishment of a multi-stakeholder forum MSF. With Kinerja’s assistance, Puskesmas Sumberasih 51 established a sub-district MSF in November 2012 that aimed to oversee, mediate, coordinate, and advocate for improvements in public health care. MSF members included community leaders, religious leaders and traditional cultural leaders, as well as government staff and CSO members. To open the door to increased public participation, one of the first activities the MSF carried out was the complaint survey. 4. Workshop on complaint handling and questionnaire development. As the first step in the complaint survey, the puskesmas and the MSF jointly held a complaint workshop consisting of 80 service users and 20 service providers. The workshop identified complaints regarding services at the puskesmas, and a list of complaints was drafted. This list became the basis of the questionnaire. 5. Complaint survey. In January 2013, Puskesmas Sumberasih’s MSF carried out the complaint survey by interviewing 140 users of MCH services. All respondents were pregnant mothers or mothers with children under two years of age. 6. Complaint index. The results of the complaint survey were ranked by frequency of response and were listed in the form of a complaint index. 7. Complaint survey analysis workshops. The complaint index was jointly analyzed by MSF members, community representatives, and puskesmas staff at a series of workshops that aimed to identify the root causes of complaints. 52 8. Drafting and signing of service charter and technical recommendations. Two types of issues were identified – internal problems that could be solved internally by the puskesmas itself, and external problems that required the help of the local government. Internal problems and their solutions were then compiled into a service charter; external problems and their solutions were written up as technical recommendations to be given to the DHO. Both documents were signed by the head of Puskesmas Sumberasih at a public event witnessed by DHO, Bappeda, the MSF, and the community. This was done in an effort to support transparency. The technical recommendations were handed to the DHO while the service charter was printed as a standing banner and displayed in the puskesmas waiting room until all complaints had been sufficiently dealt with. 9. Monitoring of service charter and technical recommendations. The local MSF was responsible for monitoring the implementation of both service charter and technical recommendations. The MSF carried out regular checks to see whether improvements had been made and promises had been fulfilled. The heads of the puskesmas and DHO were informed of monitoring results and reminded to overcome complaints that had not yet been solved. 10. Repeat of complaint survey. Puskesmas Sumberasih was so pleased with how the complaint survey helped identify problems and improve services that at the time of writing, they were planning to repeat the process and make complaint surveys a regular part of their programs. 53 Results and impact Puskesmas Sumberasih and its MSF agree that a number of significant improvements have taken place since the complaint survey was carried out. Previously, the puskesmas felt as though it was solely responsible for making improvements and overcoming any problems that occurred. The community also felt that all issues about health care were the responsibility of the puskesmas alone. Since the complaint survey, the community’s feelings of ownership and trust have increased, and the puskesmas frequently involves the MSF in meetings and workshops. There has been a measurable increase in the number of pregnant women seeking the services of Puskesmas Sumberasih since the puskesmas began actively working to improve its management of MCH services. The table below illustrates how these numbers have grown since 2011, the year before Kinerja began assisting Puskesmas Sumberasih. After two years of support, the number of deliveries assisted by medical professionals rose 6, first ante-natal check-ups by 13, and fourth ante-natal check-ups by 7. This indicates that more women trusted the puskesmas to provide them with high- quality MCH services. MCH services at Puskesmas Sumberasih, Probolinggo 2011 2012 2013 Deliveries assisted by medical professionals 926 963 979 First ante-natal check-up 1,125 1,181 1,268 Fourth ante-natal check-up 860 848 918 54 This increase is also due to the number of new partnerships between midwives and traditional birth attendants TBAs. In 2011, 128 TBAs had not yet joined into partnerships with midwives; by 2014, just 8 TBAs remained un-partnered. These partnerships require TBAs to no longer assist deliveries by themselves but to instead refer pregnant and delivering women to the puskesmas where they can be assisted by midwives. As community members trust TBAs, they then come to trust the puskesmas and its midwives. In terms of puskesmas administration and how services are provided, the biggest impact has occurred as a result of installing a fingerprint registration system for patients. During the complaint survey, 85 respondents complained that waiting times were too long over 30 minutes on average and that part of this problem was that the registration process took too long. The MSF and the puskesmas discussed this issue, and agreed to trial a fingerprint registration system that automatically links patients’ medical files with their fingerprints. Registering for an appointment now only takes a few seconds; previously, it took more than three minutes per patient. The system works even if patients have left their ID or insurance cards at home. Although it seems like only a small difference, it must be remembered that the puskesmas serves more than 100 patients a day – a saving of 2.5 minutes per patient means the system can flow much more smoothly and efficiently. The head of Puskesmas Sumberasih, Hariawan Dwi Tamtomo, said the fingerprint registration system was a direct result of the complaint survey results. “We found out that many patients complained about having to wait a long time. We’ve been using 55 a digital medical file system, SIMPUSTRONIK, since 2007, so we added the fingerprint registration syst em,” he said. Since working to improve its management and administrative systems, Puskesmas Sumberasih has won a number of awards. In 2012, it won the awards for Cleanest In-Patient Facilities and Best Performance of all puskesmas in Probolinggo district. In 2014, Puskesmas Sumberasih was ranked by the Provincial Health Office as the Second-Best Puskesmas in all of East Java. Monitoring and evaluation Monitoring and evaluation is a joint activity at Puskesmas Sumberasih, carried out by DHO, MSF, and puskesmas staff themselves. In terms of the service charter and technical recommendations, the MSF monitored its implementation once during the twelve months after the complaint survey. MSF members checked whether improvements had taken place, and The fingerprint registration system in operation at Puskesmas Sumberasih. 56 reminded the puskesmas and the DHO to follow-up if no improvements had occurred. When the puskesmas decided to run a second complaint survey, the MSF ensured that previous complaints that had not yet been dealt with were also part of the new questionnaire. Monitoring at Puskesmas Sumberasih also takes place through complaint handling mechanisms. If any complaints are received by the puskesmas, the staff discuss them and find solutions for them with MSF members at a regular mini-workshop. The Probolinggo DHO also carries out regular monitoring and evaluation of Puskesmas Sumberasih, as it does for all puskesmas in the district. Challenges When first training puskesmas staff on the complaint survey process, Kinerja and its IOs received some initial resistance towards the idea. Many staff members – medical professionals and administrative staff alike – were of the opinion that criticism of the puskesmas from the community would give the facility a bad reputation. Fortunately, the head of the Puskesmas believed that complaints would actually help the centre improve, and worked with the MSF to convince his staff members to give the complaint survey method a try. The head explained that criticism helps him and his staff identify what problems exist and what community needs are going unmet. The community also had some reservation towards the complaint survey at first. Service users were worried that if they complained about the puskesmas and its services, they 57 would later receive sub-standard health care. The community slowly began to shift their perceptions after the puskesmas explained that they were genuinely open to community feedback and promised that whatever was said would not have a negative impact on the services they provide to patients. The other main challenge was that Puskesmas Sumberasih had never carried out a complaint survey before, so they did not know how to do so. Kinerja’s IO, LPA, trained both puskesmas staff and MSF members on the process and its implementation, and incorporated complaint surveys, service charters, and technical recommendations from other districts as examples. Sustainability The high level of public participation and oversight at Puskesmas Sumberasih, as demonstrated by the local MSF, means that there is a strong likelihood that the changes achieved will be sustained. Sumberasih’s MSF has been consistently active in the two years since its establishment, and its members are still enthusiastic and interested to continue their work. The Puskesmas itself has stated its commitment to civic engagement, and has begun to involve the public in more of its regular management and administrative activities, such as planning, budgeting, and monitoring. The head of the Puskesmas is keen to continue working with the MSF. Kinerja and its IOs have supported more than 100 puskesmas throughout Indonesia to carry out complaint surveys since 2012. Local governments have begun replicating the process at 58 other puskesmas since seeing the impact it has had on pilot puskesmas, while many puskesmas who have already run the complaint survey once are interested in repeating the activity. On average, 80 of complaints put forward during the survey have been dealt with at Kinerja’s original 61 partner puskesmas. Lessons learned and recommendations Puskesmas Sumberasih ’s experience in carrying out a complaint survey and implementing a service charter has shown that co- operation between community members and health facilities has a positive impact on the quality of public service delivery. Problems are not only more easily identified but also more easily solved. The key lessons can be summarized as follows: - A service charter and list of technical recommendations become a bridge to improved transparency and accountability because they are based on not what the puskesmas thinks the community needs, but on what the community thinks the community needs. - Technology can be an effective way of speeding up services and increasing efficiency. Technology such as fingerprint registration is also simple to use and makes life easier for patients, as they no longer need to bring their ID and insurance cards. - Having a manager on duty to oversee daily activities at the puskesmas is an effective way of ensuring SOPs are followed and that patient needs are met. - Personal and informal advocacy from key figures, such the head of the puskesmas, can change long-held attitudes and mindsets. 59 Over 100 puskesmas throughout Indonesia have now undertaken the complaint survey process and developed service charters. In general, puskesmas who have made improvements based on service charters are cleaner and in better condition in terms of infrastructure; are served by friendlier, more polite staff; provide services in line with national standards; deliver more babies; carry out more ante- natal check-ups; and support more mothers to immediately and exclusively breastfeed their babies. Most importantly, both staff and patients are more satisfied with puskesmas services, and health outcomes are starting to improve. Contact details Dr Hariawan Dwi Tamtama Head of Puskesmas Sumberasih +62 335 427268 Lily Pulu Former Public Service Oversight Specialist, Kinerja USAID lily.pulugmail.com 60 Improving promotion of immediate and exclusive breastfeeding Background Exclusive breastfeeding is when babies are fed only breastmilk for the first six months of their lives, and receive a combination of breastmilk and other foods until the age of two years. Exclusive breastfeeding has been proven to improve the nutritional status of babies and strengthen immune systems. Levels of exclusive breastfeeding are low in Indonesia. According to national data from 2012, only 33.6 of babies under two are breastfed by their mothers. This is influenced by low levels of understanding about breastfeeding in addition to local cultural beliefs and misconceptions. Many mothers believe that breastmilk does not provide adequate nutrition for their babies, so they give them additional food and drink such as honey, coconut water, and over-cooked rice even though they are under six months of age. A high proportion of mothers also choose to give formula milk rather than breastmilk because it is considered to be better for babies’ growth, more modern, and healthier. In some parts of Indonesia, mothers also believe that colostrum the first breastmilk is dangerous for babies and must be disposed of, which leads to a reliance on formula milk during the very important first few days of life. Some mothers avoid breastfeeding because of the belief that it will cause their breasts to droop and sag. Many are also embarrassed to 61 breastfeed in public, or simply find using formula and a bottle easier. Other factors also come into play. In Indonesia, one key influencer is the formula milk industry, which carries out intense advertising and promotion of its products. Following bans on advertising formula milk for babies under the age of two on TV and in print, formula milk producers instead have widely entered into partnerships with health facilities and midwives, offering prizes and rewards for those who promote and sell formula milk. It is common to see formula milk logos and slogans on medical products and products for new mothers, and many midwives have side businesses in selling formula milk. This issue is compounded by the lack of promotion on immediate and exclusive breastfeeding from health facilities and district health offices DHOs, although the situation has begun to change in the last few years. On paper, some community health centers puskesmas have plans to promote immediate and exclusive breastfeeding, but many do not. Unfortunately, even amongst puskesmas who do carry out breastfeeding promotion, activities are generally limited in scope and have minor impact. In an attempt to improve the quality and impact of such activities, Kinerja worked with puskesmas to make their breastfeeding promotion more relevant, more interesting, and more participatory. Some of the most interesting approaches to breastfeeding promotion occurred in Bener Meriah in Aceh, in Tulungagung and Probolinggo in East Java, and in Makassar in South Sulawesi. In 2010, exclusive breastfeeding was low in all four of these districts. In Bener Meriah, just 40 of children under the age of 62 two were exclusively breastfed. In Tulungagung, the rate was 52.5; in Probolinggo, 34; and in Makassar, 59. Kinerja’s aim was to improve the awareness of the importance of immediate and exclusive breastfeeding, with the longer-term goal of improving breastfeeding rates. Program Innovation Each Kinerja partner district that worked on improving breastfeeding promotion developed its own approach, designed to be effective in the local cultural context. Co-operation between the Office of Religious Affairs and puskesmas: Bener Meriah, Aceh A long-held myth in Bener Meriah is that breastmilk contains bacteria that are dangerous for babies. Called dena in the local language, this myth is so wide-spread that the majority of mothers in the district give their babies formula milk, with some also using the water in which rice is cooked as an additional drink. This myth also means that many new mothers refuse to carry out immediate breastfeeding, despite the advice of midwives. Colostrum is considered to be ‘bad milk’ that has gone stale, so is generally not given to babies. Local knowledge of the importance of exclusive breastfeeding is also low, as many midwives and doctors do not explain this to pregnant women and their families. Unfortunately, this has led to weakened immune systems amongst babies. Diarrheal illnesses are also common due to a lack of clean water available for mixing formula milk. 63 Bener Meriah decided to attempt to improve rates of immediate and exclusive breastfeeding by including information on these topics in the pre-marital courses run by the local Office of Religious Affairs. All couples intending to marry are required to attend these courses, and since 2013, health professionals such as the head of puskesmas and the head midwife have been included in the courses to give information on breastfeeding and safe childbirth. Crucially, the Office of Religious Affairs provides religious justification for breastfeeding in the form of a fiqh booklet containing religious law that supports breastfeeding. The booklet was developed in coordination with the District Ulama Council, the Islamic Law Office, the District Health Office, puskesmas, and local religious and community leaders. All couples intending to marry must participate in the one- week pre-marital course before their wedding. On average, Bener Meriah holds five or six courses every year. Couples receive information on maternal and child health, preparing for childbirth, the delivery process, and immediate and exclusive breastfeeding. All couples are given a copy of the fiqh booklet. The booklets are also available to read at the puskesmas. Formula Milk Ban: Puskesmas Beji, Tulungagung, East Java Puskesmas Beji, one of Kinerja’s partner puskesmas in Tulungagung district, East Java, took the brave decision in May 2013 to ban all formula milk promotion and sale in their catchment area. The puskesmas ended its partnership with a formula milk producer and stopped offering products at both the puskesmas itself and the numerous village-level birthing 64 clinics. Staff are also forbidden to become promoters or salespeople for formula milk products. The decision was made by the head of the puskesmas following demands from community oversight bodies. It was also in line with a new district regulation that forbids the promotion and sale of formula milk in health facilities. In order to support the ban, the puskesmas stepped up its efforts to promote immediate and exclusive breastfeeding. The staff began new community education programs which aimed to overcome two key local misconceptions: that babies only cried because they were hungry, and that formula milk is the best food for babies. Integrated Breastfeeding Campaign: Probolinggo, East Java The government of Probolinggo district in East Java are strong supporters of immediate and exclusive breastfeeding because of Breastfeeding mothers say Breastmilk is the best at Puskesmas Beji, Tulungagung. 65 the huge nutritional and immune benefits they provide to babies. Since beginning its work with Kinerja, the district government has so far developed a district head regulation that supports breastfeeding and safe childbirth; sponsored community festivals and healthy food competitions; elected breastfeeding ambassadors; and provided training to religious figures on how to support breastfeeding and why they should do so. One high impact activity the government of Probolinggo did was to elect the District Head, Hj. P. Tantriana Sari, as a breastfeeding ambassador in 2014. As both the elected leader of the district and a mother herself, the District Head can play an important role in convincing families on the importance of breastfeeding. Ms Tantri, as she is commonly called, even made a commitment to continue breastfeeding her young child while working as District Head. She also issued a decree that instructed all work places and public places to establish breastfeeding rooms and that forbade health facilities and private midwives from selling formula milk. Ms Tantri also regularly drops in at puskesmas unannounced to ensure they are not promoting or selling formula milk products. A number of government buildings have already followed the decree and have set up breastfeeding rooms, including at the district parliament, the district health office, two hospitals, and seven puskesmas. With the clear and active support of the District Head, the people of Probolinggo can see that the government is truly committed to supporting immediate and exclusive breastfeeding. Mothers report feeling strengthened in their 66 decisions to breastfeed, and as though they are able to do so without worrying about discrimination or stigma. The community has also been active in supporting breastfeeding mothers. Twenty-two sub-districts have each formed Breastfeeding Support Groups. Consisting of mothers and community members concerned about low breastfeeding rates, the groups meet regularly to discuss challenges and successes, and to share information about breastfeeding and child health. One of the most creative breastfeeding promotion activities has been carried out by the district’s puskesmas – the planting of katuk and kelor plants. Both are locally-grown but not widely- consumed, despite their nutritional value, as are often viewed as ‘poor people’s food’. Katuk sauropus androgynous is a leafy plant which, if consumed, is believed to encourage the production of breastmilk. Kelor moringa oleifera, on the other hand, is a nutritious leafy plant which contains high levels of Vitamins A, B2, B6 and C, iron, and magnesium. A District Head Decree has instructed all health facilities to develop and maintain small gardens that include both katuk and kelor plants, and to prepare meals for new mothers made of these leaves. Some puskesmas also give out seedlings of katuk and kelor to expecting mothers as an incentive to attend ante-natal check- ups. Our Community Cares about Breastfeeding: Makassar, South Sulawesi Although there are now numerous breastfeeding movements throughout Indonesia, the majority are dominated by women. Few men tend to be involved. This is because breastfeeding is considered to be a ‘women’s issue’. 67 With Kinerja’s assistance, the city of Makassar in South Sulawesi has carried out a wide-reaching breastfeeding awareness raising campaign directed at men. It aims to encourage men to become advocators for and supporters of breastfeeding. The campaign began by attempting to change the idea that breastfeeding is only something women should care about, by establishing groups called Fathers Who Care about Breastfeeding. The groups’ members are made up of professors, public servants, religious leaders, community leaders, neighborhood heads, and other community members. The groups aim to increase the rates of immediate and exclusive breastfeeding through making men aware that their children’s health is not just their wife’s responsibility but theirs as well. I augurati g the it ’s e E lusi e Breastfeedi g A assadors i Makassar, South Sulawesi, in 2013. 68 The Fathers Who Care about Breastfeeding groups run education activities at the sub-district and neighborhood levels. They provide advice to new mothers and fathers on exclusive breastfeeding, and promote its nutritional benefits over formula milk. The groups’ members are also now often involved in discussions, workshops and trainings on breastfeeding as facilitators and presenters. In 2014, the groups worked with the city’s Multi-Stakeholder Forums MSFs – community forums established by the Kinerja program to oversee public service provision to develop a peer learning module for breastfeeding supporters. The module was designed to increase the knowledge and understanding of supporters on immediate and exclusive breastfeeding, and to improve their capacity to provide support and advice to families encountering breastfeeding problems. Implementation Process Co-operation between the Office of Religious Affairs and puskesmas: Bener Meriah, Aceh Bener Meriah’s District Health Office DHO realized that one of the biggest factors behind low breastfeeding rates in their district was the persistence of the dena myth, which claims that breastmilk contains bad bacteria. The DHO began a series of discussions with local partners, such as puskesmas, the Office of Religious Affairs, the Islamic Law Office, and others, talking about what could be done to eradicate the myth. The stakeholders agreed to develop a program to overcome the misconception. 69 One of the recommendations that came out of the discussions was to develop a partnership between the Office of Religious Affairs and the district’s puskesmas in order to promote good maternal and child health to couples about to be married. This was considered a strategic way of reaching key communities, as both men and women have to attend pre-marital courses run by the Office of Religious Affairs. A Memorandum of Understanding MOU was developed between the Office of Religious Affairs and Bener Meriah’s puskesmas to run pre- marital courses that include information on safe delivery and immediate exclusive breastfeeding in addition to the regular material provided. Following the signing of the MOU, staff from the Office of Religious Affairs were trained by staff from the DHO and puskesmas on safe childbirth and breastfeeding. These staff were required to share their new learning with other staff at the Office of Religious Affairs to ensure that all were aware of not just breastfeeding but of how the Qur’an and hadiths support it. A separate team was established to oversee the creation of a fiqh booklet Islamic law booklet about breastfeeding from an Islamic perspective. The team included members from all key stakeholders, both religious and health. The booklet would be given to couples about to be married, as well as to Islamic scholars and preachers to use in their sermons and study sessions. Formula Milk Ban: Puskesmas Beji, Tulungagung, East Java As with many other districts in Indonesia, Tulungagung’s hospitals, puskesmas and private midwifery practices have 70 previously signed contracts to become distributors of formula milk. According to the head midwife of Puskesmas Beji, Ari Murtiningtyas, this was because the health workers feel that they are making it easier for mothers to purchase formula milk, because they do not have to go to a separate shop anymore. Fortunately, this attitude is now changing. Puskesmas Beji decided to end their contract in May 2013 and ban the promotion and sale of formula milk throughout their catchment area. To ensure this ban is implemented, village midwives undertake monitoring visits to private midwives to ensure they are not selling formula milk, and house visits to educate families on breastfeeding. Integrated Breastfeeding Campaign: Probolinggo, East Java The government of Probolinggo began its integrated breastfeeding campaign by developing a district head regulation. This regulation gives a strong legal basis for breastfeeding campaign activities; regulations like these are very important in Indonesia. After the development of the regulation in mid-2013, the government carried out the following activities: 1. The District Head was elected as a breastfeeding ambassador for 2013. 2. A workshop for Islamic scholars and preachers on safe childbirth and immediate exclusive breastfeeding to ensure religious leaders were in agreement with and supported the campaign. 3. Twenty-two sub-district Groups who Care about Breastfeeding groups were formed. 71 4. In November 2013, the District Head instructed health facilities to plant katuk plants to support breastfeeding. 5. In January 2014, the District Head instructed health facilities to plant kelor plants to improve maternal and child nutrition. 6. In March 2014, the government held a katuk and kelor food festival at which more than 200 different menu items were cooked. 7. A series of trainings for 60 traditional medicine sellers, vegetable sellers, and make-up artists were held to encourage them to share information on safe delivery and breastfeeding with their customers and clients. 8. A training for health volunteers on how to better support breastfeeding mothers was run. 9. A training on breastfeeding was held for 49 breastfeeding counsellors. 10. In October 2014, 24 new breastfeeding ambassadors at the sub-district level were elected. After being elected, the new ambassadors were trained on safe delivery and immediate exclusive breastfeeding, and developed their work plans for the next 12 months. A bridal make-up artist left who received training on how to discuss breastfeeding with brides-to-be. 72 Our Community Cares about Breastfeeding: Makassar, South Sulawesi The pro-breastfeeding movement in Makassar began in 2012 with a new district head regulation on exclusive breastfeeding. This provided the legal framework for promotional activities on breastfeeding. Kinerja supported the district to establish multi-stakeholder forums MSFs on health service delivery in its partner sub- districts. The community took this idea one step further after realizing that there was a lack of men involved in maternal and child health issues, and established a series of Fathers who Care about Breastfeeding groups. The MSFs and the Fathers groups then worked together to develop the peer learning module for breastfeeding supporters. Results and impact Co-operation between the Office of Religious Affairs and puskesmas: Bener Meriah, Aceh Since incorporating safe delivery and breastfeeding information into pre-marital courses, the rates of newly-wed couples carrying out immediate and exclusive breastfeeding have increased. For example, during the first six months of the program that is, between June and December 2013, 13 couples took part in the course. Ten have since become pregnant, and eight of these have given birth. All eight chose to do immediate breastfeeding, and were still breastfeeding their children at the time of writing. This means that there is a 100 success rate so far. 73 From January to September 2014, 28 couples took part in the course. All have stated their commitment to carry out both immediate and exclusive breastfeeding. Formula Milk Ban: Puskesmas Beji, Tulungagung, East Java The impact of Puskesmas Beji’s formula ban is impressive. Within just two months of implementing the ban in May 2013, the rate of breastfeeding in the puskesmas ’ catchment area increased from 55 to 88. Eight villages were already formula milk-free within a month of the ban. It is clear that the increase was related to the ban, as rates of immediate breastfeeding were already 100 at the puskesmas and there were no other promotional activities that went on at the time. In addition, 80 of privately-practicing midwives have ceased promoting or selling formula milk at their clinics. Integrated Breastfeeding Campaign: Probolinggo, East Java Immediate and exclusive breastfeeding have been proven to improve a baby’s nutritional status. Although this link has not been explicitly studied in Probolinggo, the District Health Office believes that better maternal nutrition and increased rates of immediate breastfeeding are part of the reason behind a drop in the neonatal mortality rate NMR. In 2012, 230 babies died in Probolinggo; this fell to 201 in 2013, representing a drop in the NMR from 12.43 deaths per 1,000 live births to 11.04 deaths per 1,000 live births. Our Community Cares about Breastfeeding: Makassar, South Sulawesi As a result of numerous promotional and awareness raising activities, exclusive breastfeeding rates increased significantly in 74 Makassar between 2012 and 2014. At Kinerja’s three partner puskesmas in the district, rates increased by more than 20 percentage points on average. Rates of exclusive breastfeeding at Kinerja’s partner puskesmas in Makassar, South Sulawesi 2012 2014 Puskesmas Cenderawasih 58 76 Puskesmas Batua 61 84 Puskesmas Patingalloang 48 72 The overall average breastfeeding rate in Makassar also increased, reaching 67.8 in 2013, up from 61.35 in 2012. The change in attitudes of mothers and fathers to breastfeeding has also been positive. Women are no longer embarrassed that they breastfeed their child breastfeeding is seen as something that only poor women do in many parts of Indonesia; in fact, now they are proud. Their husbands and families are also much more supportive of their choice to breastfeed than previously. Monitoring and evaluation Co-operation between the Office of Religious Affairs and puskesmas: Bener Meriah, Aceh The head midwife of each puskesmas monitors the rates of immediate and exclusive breastfeeding at her own puskesmas and at the village-level birthing clinics. She also meets with new mothers and mothers with young children to discuss their breastfeeding problems and successes, and to ask for feedback on how the puskesmas can better support them. 75 The staff of the Office of Religious Affairs work together with midwives from the puskesmas of Bener Meriah to examine the impact of the program. They compare data to see whether couples have undertaken the pre-marital course and if they then follow through with immediate and exclusive breastfeeding. Formula Milk Ban: Puskesmas Beji, Tulungagung, East Java There is no formal system for monitoring the sale of formula milk at facilities in the sub-district yet, but some informal monitoring has taken place. The head midwife regularly visits the village-level birthing clinics and the private homes of midwives to ensure they are not selling formula milk and to remind them to provide information on breastfeeding to all pregnant women and their families. One unexpected result of this program has been that the quality of data recorded by the puskesmas and the village-level birthing clinics has improved. Data is more regularly recorded than previously, and the clinic believes it is more accurate because of this. Integrated Breastfeeding Campaign: Probolinggo, East Java The monitoring of the breastfeeding campaign in Probolinggo has so far been limited to activities carried out by the multi- stakeholder forums MSFs. The MSFs have developed monitoring tools to gather data on the rates of breastfeeding in the district, and will use the data collected to make recommendations to the DHO. 76 Our Community Cares about Breastfeeding: Makassar, South Sulawesi The Fathers who Care about Breastfeeding groups have no external monitoring or evaluation. They monitor their own activities, and solve problems collectively. They also take up more complex issues with the DHO and the puskesmas. Challenges The challenges experienced in each of the four districts profiled in this story are similar. Each faces continuing strong cultural beliefs and misconceptions about breastfeeding, as well as the Indonesia-wide preference for formula milk because it is thought to be healthier and more ‘modern’ than breastmilk. Even when mothers themselves understand the importance of breastfeeding and wish to breastfeed their babies, they will frequently encounter resistance from their husband, mother, or mother-in-law. Each district is working hard to slowly overcome these beliefs. Other problems include the low level of understanding of midwives on immediate breastfeed and the proper way to perform it; the lack of breastfeeding facilities in work places and public places; and the lack of desire among families to continue breastfeeding after the first few months. Sustainability The sustainability of each of the pro-breastfeeding programs implemented in Kinerja’s four partner districts profiled here relies heavily on community participation and support. Without the full involvement of the community, these programs will not 77 be successful and will not sustain themselves over the next few years. If the community continues to take part, however, as they are currently doing, all four of these programs have a high chance of being sustainable. Each program will also require support from the local governments, particularly from the District Health Offices. This support must include financial support to ensure the programs are able to continue. All of these programs have the potential to be replicated throughout the rest of Indonesia. Breastfeeding rates are low across the country, and districts would do well to consider the programs presented here for implementation in their own areas. Lessons learned and recommendations - District head regulations are important. Regulations such as those issue by the district head provide a legal basis for health workers to point to when they suggest to community members that they exclusively breastfeed their babies. With the regulation in place, health workers report feeling braver and more comfortable in giving breastfeeding advice to patients because they know the law and the government supports what they are doing. - Innovative campaign methods are key to building momentum. Formula milk promotion is so widespread and so strong that it has reached even the most isolated villages in Indonesia. When families see on TV or read in the newspaper that formula milk makes babies healthy and 78 happy, they can be easily influenced to abandon breastfeeding. This means that creative and interesting methods of promoting breastfeeding are necessary if the aim is to change behavior. - Individual commitment is as important as organizational commitment. The role that individuals can play is often overlooked. Kinerja’s experience in supporting districts to promote exclusive breastfeeding has shown that key individuals, such as the District Head, can have a significant impact on behavior. That said, the commitment of individuals at a smaller level is also crucial – if a few midwives do not support exclusive breastfeeding and continue to sell formula milk, for example, it is unlikely that their patients will change their behavior. Only when individuals commit to change will the community follow. - Data collection needs to be improved. One issue in almost every district Kinerja supported was the lack of or poor quality of data on immediate and exclusive breastfeeding. Data was often missing or incomplete, or had never been collected in the first place. When data did exist, it had sometimes been collected through inappropriate methods and did not actually reflect the real situation. This makes monitoring and evaluation incredibly difficult. 79 Contact information Bener Meriah Risnawati Head of Puskesmas Bukit Jl. Mesjid Babussalam, Simpang Tiga Redelong, Kab. Bener Meriah Puskesmas Beji, Tulungagung Winny Isnaini Staff, Lembaga Perlindungan Anak Child Protection Organsiation Tulungagung wisnaini2003yahoo.com Probolinggo Ana Maria Secretary, Probolinggo District Health Office annamariadsymail.com Makassar Siti Rohani Former staff, USAID Kinerja sitirohani.mksgmail.com 80 Partnerships between midwives and traditional birth attendants help to improve maternal health in Aceh and South Sulawesi Background The Indonesian government worked hard in its bid to achieve the Millennium Development Goals MDGs, and especially focused on Goal 5 Reducing Maternal Mortality. Indone sia’s goal for reducing the maternal mortality rate MMR was a 75 reduction to 112 maternal deaths per 100,000 live births. However, according to the 2012 Indonesian Health Demographic Survey IDHS, Indonesia was not on track to meet this target. In fac t, Indonesia’s MMR was increasing, and had jumped from 228 deaths per 100,000 live births in 2008 to 359100,000 in 2012. Based partly on this, the United Nations Population Fund UNFPA considers Indonesia to be one of the world’s ten worst countries to be a pregnant woman. One of the reasons behind Indonesia’s continuing high MMR is that many births are not assisted by trained medical professionals and do not occur in health facilities. This is particularly the case in rural areas, where families often choose to use traditional birth attendants TBAs because they are closer, cheaper, understand the local culture and religion, have spiritual knowledge, and are generally seen to be more experienced than midwives. However, TBAs are not medically trained and many do not fully understand what is needed for a safe birth to take place. 81 Although they are medically trained, midwives are often considered to be too young and too inexperienced, in addition to being too expensive and not familiar with local culture, religion, or language. Many midwives also do not live in the villages where they have been assigned, and so are not always available. This perception further encourages local communities to choose TBAs over midwives when a woman gives birth. To overcome this issue, the Indonesian Ministry of Health established partnerships between midwives and TBAs more than two decades ago. Kinerja’s approach has been to make these partnerships more desirable, more transparent, and more participatory. Two areas which had good success in doing so were Aceh Singkil in Aceh Province, and Luwu in South Sulawesi Province. Both districts’ programs aimed to increase the co-operation between midwives and TBAs, but took slightly different approaches and created different incentive schemes. Aceh Singkil, Aceh Kinerja assisted Aceh Singkil to establish a midwife-TBA partnership program in 2011. At the time, the district experienced a high number of maternal and neonatal deaths – five women and 35 babies died in 2011. Overall, around 30 of the district’s births were assisted by TBAs, 66 by midwives, and just 4 by doctors. Aceh Singkil has a population of around 110,000 people, who live in mountainous regions, along river banks, by the ocean, and on small islands. There are 122 active TBAs in the district and just 11 community health centers called puskesmas in Indonesian, with only one that can take in-patients. Just two 82 puskesmas are able to provide basic emergency obstetric and neonatal care BEmONC. There is one hospital, but it is not yet capable of comprehensive emergency obstetric and neonatal care CEmONC. Luwu, South Sulawesi Around 10 of deliveries in Luwu are assisted by TBAs. In some rural areas, however, the rate is much higher up to 30. Around 330,000 people live in Luwu, which reaches from the coast into the mountains. In 2012, the district recorded 15 maternal deaths, mostly due to post-partum haemorrhage and eclampsia. 49 babies also died in 2012. Like Aceh Singkil, Luwu’s health facilities do not yet meet t he communities’ needs – of the 21 puskesmas in the district, seven provide in-patient Midwives and their TBA partners pose for a photograph in front of Puskesmas Singkil in Aceh Singkil. 83 facilities and six can provide BEmONC services. There is no CEmONC-capable hospital. Program Innovation Although midwife-TBA partnerships have existed throughout Indonesia for some time, most are not well-implemented. The approach needs some improvement – for example, it is generally too top-down, does not properly take into account the interests of TBAs, does not provide strong enough incentives for TBAs to participate, does not involve the community in design or implementation, and does not incorporate enough monitoring and evaluation. Kinerja developed a new approach to implementing midwife- TBA partnerships, based on key governance principles, as outlined below. 1. Participation. Kinerja and its implementing organizations IOs – usually local CSOs – involved a huge range of stakeholders in developing, implementing and monitoring the midwife-TBA partnerships. They included community members, village heads, government staff, puskesmas staff, village midwives, TBAs, and the media. Kinerja’s IOs also helped establish multi-stakeholder forums MSFs made of community members and government representatives that assisted in monitoring the program, incorporating community feedback, and developing memoranda of understanding MOUs. 2. Transparency. The development and signing of MOUs between midwives and their TBA partners were done 84 openly and involved all the different stakeholders. The MOU signing events were held in public places, and were even sometimes attended by the Mayor or District Head as a witness. Details of the MOUs were then disseminated to the public. 3. Accountability. The content of the MOUs were agreed upon by both midwives and TBAs before being signed, and points were altered if the parties did not agree. This included information on financial incentives to be paid to the TBAs. 4. Responsiveness. Key stakeholders such as puskesmas, village heads and District Health Offices DHOs agreed to take action on any problems that may emerge during the partnerships’ implementation. Through these good governance principles, both midwives and TBAs can benefit from participating in the partnerships. As they can now work together to assist women in childbirth, their workload becomes lighter and easier – midwives are responsible for medical aspects, while TBAs are responsible for spiritual aspects and for looking after the newborn. Aceh Singkil, Aceh The District Health Office DHO of Aceh Singkil agreed to pilot Kinerja’s approach in two villages in 2012. After two years, the number of births assisted by trained medical workers had increased two-fold, and the number of risky births had decreased dramatically. The DHO decided to replicate the program to 29 other villages in four other sub-districts. 85 Aceh Singkil’s approach to midwife-TBA partnerships is quite unique. As Kinerja was aware, one of the main problems in implementing these partnerships in Indonesia has been the lack of strong financial incentives for TBAs. Without receiving some form of compensation, the TBAs feel disrespected and as though midwives have taken away their only source of income. To overcome this, the DHO of Aceh Singkil decided to pay decent incentives to TBAs agreeing to join the partnerships and no longer assist births by themselves. Every month, each TBA receives Rp.100.000 US10 from the DHO and an additional Rp.50.000 US5 from the village. For each birth she assists with her midwife partner at a health facility, she receives another Rp.50.000 US5 from the puskesmas through the new National Insurance Scheme. The TBAs of Aceh Singkil therefore feel appreciated and respected. By holding big events for the signing of MOUs between midwives and TBAs, the level of commitment and enthusiasm for the partnerships was high. The TBAs and midwives both felt as though they were now important players in the health status of their community, as they were being recognized at such a formal event. Luwu, South Sulawesi A different but also unique approach to developing midwife- TBA partnerships was also developed at one particular puskesmas in Luwu, South Sulawesi. Puskesmas Bajo Barat is one to two hours away from the capital city, Belopa, which means that local residents rely heavily on the puskesmas for healthcare. Fortunately, Puskesmas Bajo Barat offers in-patient facilities. 86 To encourage more women to give birth at the health facility with a midwife, Puskesmas Bajo Barat decided to increase the costs patients must pay if they give birth at home but are still assisted by a midwife. Giving birth at the puskesmas costs Rp.600.000 US60 but is reimbursed by the National Insurance Scheme JKN for patients who are members. Giving birth with a midwife at home, however, now costs Rp.700.000 US70, of which JKN will only reimburse Rp.600.000, meaning that the family must pay the gap of Rp.100.000. This strategy has been successful in encouraging more women to give birth at the puskesmas and its village-level facilities, poskesdes. The TBAs of Bajo Barat also receive financial incentives to take part in the partnerships. If they refer a woman in the early stages of labor to the health center, the TBAs will receive between Rp.100.000 US10 and Rp.250.000 US25 for each referral. In late 2014, the local multi-stakeholder forum MSF and the puskesmas advocated to the DHO to increase this fee. The DHO agreed to provide Rp.300.000 per referral from the 2015 budget. Midwives and TBAs in Bajo Barat hold yearly meetings to assess the partnerships. Their MOUs are re-affirmed, successes are discussed, and any challenges or problems are solved or passed onto the DHO for further action. If any midwives or TBAs are found to be disobeying the MOUs, they are sanctioned. On top of this, Bajo Barat does its best to make sure its midwives are well-equipped and always available, so that women are not scared of giving birth with them. Four midwives work at the puskesmas, and one midwife lives in each of the sub- district’s nine villages, working at the local poskesdes. The 87 head midwife also makes sure that all of sub- district’s midwives have complete midwife kits on them at all times. This is an impressive achievement, as only 39 out of 233 17 of midwives in the whole of Luwu district had midwife kits in 2014. This helps reassure women that their midwives are well- prepared to assist them in childbirth. Implementation Process The processes followed in Aceh Singkil and Luwu were very similar. 1. Identification of problems The first step was to identify problems and challenges relating to pregnancy and childbirth in the district. A meeting was held and attended by puskesmas head and staff, midwives, village midwives, health volunteers, village heads, community figures, religious figures, representatives of the Indonesian Midwives Association, youth representatives, the media, local NGOs, members of the district’s Health Board, and government staff. The meeting identified the causes of low numbers of births assisted by midwives, deciding that some of the reasons included low levels of public trust in newly-graduated midwives, midwives’ lack of ability to speak local languages, midwives’ relative lack of experience, poor relationships between midwives and the community, and the poor quality of staff and facilities at the district’s puskesmas and hospitals. 2. Establishment of multi-stakeholder forums MSFs MSFs were established at both the sub-district and district levels. At the sub-district level that is, at the puskesmas level, the MSFs are responsible for advocacy, mediation, and 88 monitoring and evaluation of health programs, including the midwife-TBA partnerships. The forums are made up of community members, government staff, health volunteers, and others interested in quality healthcare. 3. Informal co-ordination Kinerja’s IOs worked closely with puskesmas and DHOs to overcome the problems identified in step one. 4. Building a common understanding Mini workshops were held to develop common understandings and goals as to what the midwife-TBA partnerships would involve, including financial incentives. The agreement was written down in a draft MOU on Midwife-TBA Partnerships. The workshops were attended by midwives, TBAs, the DHO, health workers, village heads, puskesmas, and religious figures. 5. Village Head Decrees on incentives for TBAs To formalize and guarantee the incentives to be provided to TBAs, the village heads signed and published Village Head Decrees. 6. MOU signing After agreeing to all the conditions, the midwives and TBAs signed their MOUs at a public event witnessed by village heads, puskesmas heads, heads of DHOs, representatives of the Indonesian Midwives Association, and the community. The MOUs are to be renewed once every three years. 7. Monitoring Implementation of the partnerships are regularly monitored by MSFs. MSFs report their findings to the DHOs and puskesmas. 89 Village midwives are also responsible for monitoring the partnerships, primarily to ensure that no TBAs continue to assist deliveries by themselves. 8. Replication In Aceh Singkil, the program was replicated to an additional 29 villages in the first two years. In Luwu, the head of the DHO issued a decree to replicate Kinerja’s approach at nine additional puskesmas, including the midwife-TBA partnerships. Results and impact The level of trust between midwives and TBAs has increased significantly since the beginning of the partnerships. Both midwives and TBAs acknowledge that the MOUs make their rights, duties, and responsibilities clear, as well as making their everyday jobs easier and smoother, because now there are two pairs of hands instead of just one pair. Midwives are happy that the TBAs can handle the spiritual aspects of deliveries such as giving prayers, and TBAs are happy that midwives can deal with the medical aspects. The heads of Kinerja’s partner puskesmas say that because of the midwife-TBA partnerships, midwives now know about pregnancies earlier than before. This is because TBAs now refer newly-pregnant patients immediately to the midwives for ante-natal care. Previously, this did not always happen. Through the partnerships, mothers can now access professional health care in their local languages. Many village midwives do not speak local languages, but now they are assisted by TBAs, who are generally from the local area. The 90 TBAs thus act as a bridge between the community and the midwives. Public events and discussions during the development process have increased the community’s awareness of the importance of facility-based, midwife-assisted birth. Aceh Singkil, Aceh A small but significant increase 6 has occurred in the number of births occurring at the five sub-districts with Kinerja’s innovative midwife-TBA partnerships since they began in 2011. Births assisted by medical professionals in Kinerja’s five partner sub-districts in Aceh Singkil, 2011-2014 2011 1,476 2012 1,532 2013 1,509 2014 1,561 At Puskesmas Singkil, the pilot puskesmas for the program, the most impressive result is that the number of births assisted by TBAs has fallen from 17 in 2011 when the program started to none in 2014. The biggest drop was within the first 12 months of the program. Births assisted by TBAs in Puskesmas Singkil’s catchment area, 2011-2014 2011 17 2012 8 2013 2 2014 91 The co-operation between midwives and TBAs has also led to a higher rate of pregnant women seeking ante-natal care in their first trimester. This has been a huge change for Aceh Singkil, as culturally, many women believe that if they speak aloud of a pregnancy during the first three months, the baby will be susceptible to black magic or spirits. More than 200 more women had a check- up in their first trimester in Kinerja’s five partner sub-districts in 2014 as compared to 2011. Number of pregnant women receiving an ante-natal check- up in their first trimester at Kinerja’s five partner sub- districts in Aceh Singkil, 2011-2014 2011 1,525 2012 1,603 2013 1,649 2014 1,739 Aceh Singkil also entered its TBA-midwife partnership program into the 2015 United Nations Public Service Awards UNPSA. It won second-place for the Asia-Pacific region – the first time that Indonesia has ever won an award from UNPSA. The District Head and the Head of DHO attended the award ceremony in Colombia and presented about the program, its implementation, and its benefits. Luwu, South Sulawesi As with Aceh Singkil, Luwu also experienced an increase in the number of births assisted by medical professionals in the three districts supported by Kinerja. 92 Births assisted by medical professionals in Kinerja’s three partner sub-districts in Luwu, 2011-2014 2011 730 2012 782 2013 778 A small decrease occurred at Puskesmas Bajo Barat in 2013 due to the end of the clove and cacao farming seasons, when many migrant workers returned to their home districts. The number of pregnant women seeking ante-natal care in Kine rja’s three partner sub-districts also increased. Number of pregnant women receiving at least four ante- natal checkups in Kinerja’s three partner sub-districts in Luwu, 2011-2014 2011 670 2012 766 2013 697 As noted above, a small decrease occurred at Puskesmas Bajo Barat in 2013 due to the end of the clove and cacao farming seasons, when many migrant workers returned to their home districts. Monitoring and evaluation To ensure they have a good understanding of what is going on in their districts, puskesmas and DHOs run regular monitoring activities in both Luwu and Aceh Singkil. Head midwives visit their village midwives every month to ensure they are following the terms of the MOUs and to see how the program is progressing. The head midwives also collect monthly records of patient services during these visits. 93 In Aceh Singkil, the district’s Health Board also undertakes field visits to monitor developments. Members of the Health Board meet with midwives and TBAs to discuss problems and successes, and they later share this information with and make recommendations to the DHO. One example of how regular monitoring had a positive impact in Aceh Singkil was the creation of an emergency contact card. When a monitoring team discovered that the residents wished to be able to directly contact key persons in an emergency – such as the village midwife, the head of the puskesmas, the head midwife, or the DHO itself – they worked with the puskesmas to develop a contact card. The card lists the mobile phone numbers of people who families might need to call if a mother goes into labor and needs a midwife or ambulance. In Luwu, the multi-stakeholder forums established by Kinerja regularly attend the puskesmas ’ monthly update meetings. At the meetings, they pass on community feedback and gather information to share with community members. Challenges The main challenge in implementing an innovative, transparent and participatory midwife-TBA partnership program was the resistance to cultural change. Both Aceh Singkil and Luwu are located far from major metropolises, for example, and remain quite traditional in their cultural practices. Islam is also a major influence in both areas. TBAs are seen as having not just medical knowledge but also cultural understanding and spiritual power, so it can be hard to convince mothers to give birth with midwives instead of TBAs. 94 Midwives’ low medical skills, a lack of local language ability, and a lack of understanding of local cultural beliefs was another significant change. Patients were reluctant to give birth with midwives because they often could not communicate very well, or dismissed their cultural beliefs without explanation. A lack of financial support for multi-stakeholder forums MSFs limited their ability to carry out oversight and monitoring activities. Most MSF members are ordinary community members, and do not have a lot of spare money to contribute. Sustainability Kinerja’s midwife-TBA partnerships are more likely to be sustainable than the previous top-down versions. This is because they have taken into account the needs of both midwives and TBAs, as well as those of the community. The partnerships are based on mutual co-operation and understanding, and seek to benefit both parties. This is key, as previously many TBAs felt that their incomes were being taken away from them; now, they receive incentives for referring patients to midwives, and are able to work together with the midwives to deliver babies in facilities. The formalization of the relationships between midwives and TBAs was also crucial to their sustainability. By working together to develop MOUs and by signing these agreements at a public event witnessed by senior government members, both midwives and TBAs feel that their roles are important, respected and acknowledged. They are also able to refer back to the MOUs if they have any doubts about their roles, rights 95 and responsibilities. The MOUs also make clear any sanctions that may be implemented if the terms of the MOU are breached. The publishing of decrees from the village heads and the heads of the DHOs also helps support this formalization process, as these decrees are held in high regard by both government staff and community members. The program is also more likely to be sustained because it fulfills not only the needs but the desires of mothers. Mothers in Luwu and Aceh Singkil are very happy to be able to receive modern medical care from a midwife at the same time as getting spiritual care from a TBA. Health outcomes are also likely to improve, as the midwife can look after the mother and the TBA can look after the newborn. A TBA left and her midwife partner at an event in Jakarta celebrating Aceh Singkils second-place win at the 2015 United Nations Public Service Awards for its TBA-midwife partnership program. 96 Lessons learned and recommendations The midwife-TBA partnerships in Aceh Singkil and Luwu only succeeded because of high levels of commitment from both the community and the government. Without this strong co- operation, it is unlikely that the programs would have had a significant impact. - Community participation is key to success. Community members will have a hard time accepting and supporting new programs if they have not been actively involved in all phases, from design through to implementation and monitoring. - Stakeholders must trust each other. It is important that the roles of all parties involved in a program are acknowledged and respected as actors of change. - Appropriate incentives are required for behavior change. Incentives that are deemed sufficient by all parties are necessary to garner support. It is important that the source, amount, and method of provision of incentives is clearly defined in official documents such as MOUs, in addition to who is entitled to incentives and for what tasks they will receive incentives. - Regular and consistent communication makes implementation smoother. Regular supervision and monitoring visits from head midwives to villages, for example, ensured the midwife-TBA partnerships remained active and were well-implemented. Creative methods of encouraging communication are also useful, such as the development of the emergency contact card in Aceh Singkil, 97 which provided the contact details of key parties head midwife, village head, DHO, etc. to expecting mothers. - Changing cultures and traditions is not easy. Traditions are obviously well-embedded in communities, and require significant time and effort to change. To do so, strategies and approaches that are culturally-relevant and appropriate to the local context must be developed and used. The midwife-TBA program is a good example of this, as it combines the traditional health practice giving birth with a TBA with the modern health practice giving birth with a medical professional, and offers patients the best of both. This has meant that the community has been happy to alter their behaviors. Contact information Aceh Singkil, Aceh Edy Widodo Head of Aceh Singkil District Health Office edywidodo1967gmail.com +62 6581202 Luwu, South Sulawesi H. Abdul Aziz Head of Service Provision, Luwu District Health Office +62 47121145 98 Preventing child marriage through reproductive health education for teenagers in Bondowoso, East Java Background Gender inequality remains a major challenge in Indonesia with regards to development. According to the United Nations Development Program UNDP’s gender inequality survey, Indonesia ranked only 102 out of 148 countries in 2012. Just 36.2 of Indonesian women have a completed junior high school, for example. Maternal mortality and teenage pregnancy occur significantly more frequently in Indonesia than in neighbouring Southeast Asian and Pacific countries. It is estimated that 48 of every 1,000 live births in Indonesia in 2015 was to a teenage mother. Teenage pregnancy is also one of the driving causes of maternal mortality, which remains incredibly high throughout the archipelago, with 359 mothers dying for every 100,000 live births in 2014. In recent years, the government of Indonesia has focused its efforts on reducing the number of maternal deaths. In 2014, the national government launched a national action plan on how to reduce maternal mortality. The plan focused on improving access to ante-natal care for all mothers, including teenagers. The issue of teenagers was seen as key to the success of the plan, as child marriage remains common especially in rural areas 99 where health access is more difficult. According to a 2013 report from SMERU, economic factors are the main factor behind child marriages in Indonesia. Social and cultural forces are also influential. Bondowoso, a district in East Java, is one district where child marriage is widely-practiced. In fact, Bondowoso ranks as the district with the highest rate of child marriage in all of East Java, with more than 50.9 of marriages in 2011 involving children. Unfortunately, child marriage is more common amongst underprivileged families because it is seen as a way of reducing a family’s financial burden. Child marriage is also seen as a cultural tradition in Bondowoso. In Javanese and Madurese culture, especially in rural areas, parents begin to worry about their children if they are not married by the age of 15. Religion, specifically Islam, also contributes to high levels of support for child marriage in Bondowoso. Many people believe that the best way of ensuring that children avoid pre-marital sex, which is seen as a sin, is to get married young. This belief is complicated by low levels of knowledge about reproductive and sexual health for adolescents. The information that early marriage can be physically dangerous for girls is not widely- known, for example. Child marriage not only impacts a girl’s health but her welfare. Many girls are forced to drop out of school when they get married. This leads to a cycle of poverty that is hard to break: because she has only a basic education, she cannot get a well- paying job, and because she cannot get a well-paying job, she 100 cannot pay for her children’s schooling and health needs. This is reflected in Bondowoso’s continually low Human Development Index HDI, which is the second lowest of all 38 districts in East Java. Program Innovation In order to begin solving the problem of high maternal mortality and high rates of child marriage, the government of Bondowoso worked with Kinerja and its implementing organizations IOs to develop a reproductive health program for students, parents, and broader society. The main objective of the program is to increase awareness of the importance of reproductive health education for teenagers, to reduce the frequency of child marriage, and to reduce the maternal and neonatal mortality rates. A Bondowoso teenager and her artwork encouraging other teenagers to learn about reproductive health, avoid casual sex, and delay marriage. 101 In 2012, the government of Bondowoso worked with the Indonesian Family Planning Association PKBI – Perkumpulan Keluarga Berencana Indonesia to conduct a baseline survey on maternal and neonatal death in the district. Following the baseline, a community forum known as the multi- stakeholder forum MSF was developed, made up of community members who care about maternal and child health. The MSF advocated to the government to give extra attention to youth reproductive health, following which the District Head developed a decree covering safe delivery, immediate exclusive breastfeeding, and youth reproductive health. The District Head also issued an instruction letter which identified a number of community figures, including his own wife, who would become Reproductive Health Ambassadors. The District Head’s wife was elected as the lead ambassador and was given the title of ‘Mother of Reproductive Health’. She became very active in promoting youth reproductive health, and has taken part in many activities since assuming her role. Religious figures, both male and female, play an influential role with regards to child marriage in Bondowoso. The community strongly respects religious figures, and frequently consults them on important issues. In order to ensure they give accurate and relevant advice on child marriage, the Bondowoso District Health Office DHO worked with religious figures and provided them with training on maternal and child health. Following the trainings, religious figures who attended were able to provide information on the physical and mental risks of child marriage and pregnancy. Religious figures in Bondowoso 102 are now strong supports for the district government’s youth reproductive health program. The DHO worked with a national NGO, the Women’s Health Foundation YKP – Yayasan Kesehatan Perempuan, to carry out awareness raising activities and trainings on youth reproductive health at schools in Bondowoso. These activities involved both students and teachers, and led to the formation of a number of community groups. One of these is the Union of Teachers who Care about Reproductive Health, which was founded by a number of teachers who were concerned about the high rate of girls who dropped out of school following getting married andor pregnant. The teachers in the group began including reproductive health information in the annual orientation sessions for new junior and senior high school students and during biology classes. The teachers worked together with community leaders and members of the Family Welfare Movement PKK – Pembinaan Kesejahteraan Keluarga to share reproductive health information with young people and their parents to ensure that all are aware of the risks associated with child marriage. The students themselves also formed a community group and a peer-learning program. The group, called the Blue Sky Community Komunitas Langit Biru, worked with a local NGO, Hometown Kampung Halaman, to use media to raise young peoples’ awareness of their reproductive health. This activity has been strongly supported by the DHO, as they recognize the fact that young people are more likely to listen to their friends and peers. The group meets every two weeks, and runs regular awareness raising activities. A peer-learning program was established in four sub-districts, and has since 103 been expanded to a total of 25 sub-districts. From reaching just 24 students in the program’s first year, by 2015 the peer- learning program has trained 279 students in reproductive health issues. Together, all these activities have contributed to a significant decrease in the rate of child marriage in Bondowoso. In 2011, 51 of all marriages in Bondowoso involved children under the age of 18; in 2012, the percentage fell to 50, and in 2013, it fell again to 43 - a huge drop of seven percentage points, or 14 of total marriages, in just one year. Such a large improvement has never before been recorded in Bondowoso. Implementation Process Kinerja and the government of Bondowoso jointly decided that a program focused around youth education and empowerment as likely to be the most effective way of reducing rates of child marriage. If children can be reached while they are still teenagers, they are more open to learning different ideas. This is important, because in 2011, 51 of marriages in Bondowoso involved children. Research from PKBI also showed that 52 of women with children under the age of 12 never graduated from primary school, meaning that early intervention is crucial to reversing child marriage rates. Based on PKBI’s research and advocacy from the district’s MSFs, the District Head of Bondowoso issued a District Head Regulation in 2012 on safe delivery and exclusive immediate breastfeeding. The regulation also covers reproductive health education for young people. The District Head also appointed his wife as the ‘Mother of Reproductive Health’ and the wives 104 of village and sub-district heads as reproductive health ambassadors, tasked with supporting youth reproductive health education in their respective areas. The women elected as reproductive health ambassadors involved young people in their outreach work by including them on monitoring visits to villages. The women aimed to investigate whether there were any families planning on marrying off their young daughters. If such cases were identified, the ambassadors and young people provided the family with information on the risks of child marriage and the benefits of delaying marriage. The families were encouraged to let their daughters finish school before marrying. To expand the reach of the program, the District Head and the District Health Office decided to involve all layers of society, including religious figures, community figures, teachers, health workers, NGO workers, women’s groups, and youths. These representatives were chosen as program implementers because they are the people who interact directly with youths every day. Everyone involved plays a slightly different role based on their usual tasks and responsibilities. For example, the DHO and partner NGOs carry out reproductive health education for teenagers, teachers, health workers, and religious figures. Other community members became involved in different ways, e.g. 50 religious teachers took part in a competition and developed special seven-minute sermons on youth reproductive health and the importance of delaying marriage. After the competition, the religious teachers took their new 105 knowledge back to their mosques and began incorporating the material into their other work. One unique element of the program is the incorporation of youth reproductive health into orientation week for all new junior and senior high school students. Previously, new students never received this sort of information during their orientation period. School teachers were also taught how to add reproductive health knowledge into their existing classes. Teachers involved in the Teachers who Care about Reproductive Health group also visited every sub-district in Bondowoso to reach out to local officials and parents to improve their knowledge of youth reproductive health and child marriage. Bondowoso students learn from their peers about reproductive health and child marriage. 106 Community awareness raising on the dangers of child marriage was carried out through a range of different events, such as trainings, festivals, and competitions. One of the most successful events was the ‘My Health, My Future’ competition. Local teenagers wrote articles, made short films, and designed promotional posters on youth reproductive health. The festival was held at the District Head’s office and was attended by around 400 students from 27 junior and senior high schools. More than 300 students registered for filmmaking training sessions, despite only 50 places being available. The students learnt to make short films, some of which are now available on YouTube, such as ‘Tak Mau Seperti Ibu’ ‘I Don’t Want to Beco me Like Mum’, a film about a woman who married when she was just 12 years old. The film aims to encourage young girls to stay in school and delay marriage. Awareness raising was also carried out through radio talk shows. A number of Bondowoso radio stations regularly allocated time to talk about reproductive health and child marriage, especially on Saturdays when many young people tend to listen to the radio. The radio shows also gave teenagers the opportunity to call or SMS questions to have them answered on air. Results and impact Many useful outputs emerged from the youth reproductive health program in Bondowoso, including: a. The District Head Regulation on Safe Delivery and Immediate Exclusive Breastfeeding. b. Two District Head Decrees on reproductive health ambassadors, which encouraged the wives of village and 107 sub-district heads to support youth reproductive health. At the time of writing, 219 wives of sub-district heads and 23 wives of village heads had agreed to become reproductive health ambassadors in their areas. The position of reproductive health ambassador is now respected in Bondowoso and recognized as a source of accurate information and knowledge. c. Peer educators, who were trained and educated on reproductive health and child marriage. Peer educators came from all age groups, not just teenagers but also parents, teachers, and other community members. d. The inclusion of reproductive health information into orientation week material for new junior and senior high school students. e. The establishment of the Teachers who Care about Reproductive Health group. The group has so far undertaken a roadshow to sub-district and village heads in Bondowoso to spread the message of how child marriage endangers young women. f. The founding of the Blue Sky Community. The teenagers involved in this group target other youths and aim to improve their understanding of their reproductive health and rights. The Community has already printed articles in local newspapers, made short films, and participated in radio talk shows. The outcomes of Bondowoso’s program to delay child marriage have also been positive: a. The percentage of marriages in Bondowoso involving children under the age of 18 fell by 14 in just two years. In 2011, 51 of all marriages involved children, and in 2012, this remained high, at 50. However, by 2013, this rate had 108 fallen to 43 - a drop of seven percentage points in just one year. This is a great success. b. Anecdotal evidence indicates that more young girls are staying in school and delaying marriage. This means they are able to earn a better salary and do not need to get married for purely economic reasons. c. Young girls are better-supported to make decisions for themselves based on fact, rather than being pushed by family members to make hasty choices. d. Girls are empowered to protect their reproductive health and control their own fertility. By taking part in youth reproductive health education programs, girls receive information that they otherwise miss out on, meaning that they will be healthier throughout their whole lives. e. The risk of maternal and neonatal mortality and morbidity decreases as women know more about their own body, health, and rights. Young girls have been shown to be at significantly increased risk of death as a result of pregnancy and childbirth because their bodies are not yet physically ready; by delaying marriage and childbearing, girls are more likely to have safe and healthy pregnancies and children. f. The Human Development Index HDI has improved in Bondowoso in line with reduced child marriage rates. In 2011, it was 63.81, and by 2013, had risen to 65.42. g. Traditional beliefs are slowly disappearing. Reproductive health is no longer seen as a taboo topic in Bondowoso, and is now discussed openly by all. The stigma surrounding unmarried girls over the age of 15 has also begun to decrease, primarily thanks to the strong involvement of religious teachers and community leaders in the district’s anti-child marriage campaign. 109 Monitoring and evaluation The government of Bondowoso primarily monitors changes in attitudes towards child marriage by analyzing marriage statistics. The DHO collects annual data on youth reproductive health, and compares its own data and data from other government bodies with the information collected by PKBI in 2011. This helps the DHO see trends and year-on-year changes. Informal monitoring is carried out by groups and individuals such as the reproductive health ambassadors and peer educators, who monitor occurrences of child marriage and attempt to discourage families from marrying off their young daughters. Many community members are now also paying careful attention to local gossip and rumours, and if they hear of any upcoming child marriages, they contact a reproductive health ambassador, who visits the family in question. All of this information is generally passed on to the district government for recording. Challenges This program aims to change old ways of thinking and traditional beliefs on child marriage in Bondowoso. It is not surprising, then, that the major challenge has been cultural, particularly in terms of overcoming the genuine belief that girls who are not married by the age of 15 will face problems finding a husband. Child marriage is also seen by many Bondowoso residents as a way of ensuring young people are not sexually active before marriage. Pre-marital sex is a major taboo in the district, and is generally seen as something that should be avoided at all costs. 110 However, this mindset is problematic, because it means that even talking about sex is taboo, which results in young people not being given the reproductive health information they need. Economically, it has also been hard to change parents’ ways of thinking. Marrying off a teenage daughter is often seen as a solution to financial challenges, as it means that there is one less family member to feed. These cultural and economic challenges will inevitably take many years to overcome. The situation is made even more difficult because of low levels of education – the average resident of Bondowoso has just 5.94 years of schooling. The district government and local NGOs are attempting to solve this issue by making broad public participation a central element of their programs, targeting not just children but also their parents and key community figures. Sustainability The issuance of a District Head Regulation and two decrees relating to youth reproductive health and child marriage mean that the legal basis exists for continued focus on these topics. This is very important as it illustrates to the community that the government and its elected head supports change. The inclusion of reproductive health information in school subjects and the orientation period for new students is an excellent development, and will be crucial moving forward. It will ensure that all students are reached with information on the importance of knowing their bodies and delaying marriage. 111 The government has committed to continue the reproductive health-inclusive orientation program into the future. The fact that both men and women and boys and girls are actively involved in the program greatly supports its chances of sustainability. The involvement of male religious figures is particularly exceptional as, unfortunately, Islamic figures throughout Indonesia frequently provide incomplete reproductive health information. The district head’s wife and women’s groups have been excellent role models in promoting youth reproductive health and the risks of child marriage to local residents, especially women and girls in marginalized communities. Most importantly, teenagers themselves have been involved in the program with a leading role as educators and role models for their peers through art and the media, as well as through the election of youth ambassadors – a highly- coveted position. Local teens are now encouraged to speak publicly about youth reproductive health. This ensures that the topics of reproductive health and child marriage will not disappear from sight. Lessons learned and recommendations The key to the success of the reproductive health program in Bondowoso lies in co-operation. The program was and continues to be implemented by a wide range of partners: Kinerja USAID, a number of local NGOs, the Bondowoso District government, the Bondowoso District Head and his wife, village and sub-district governments, health workers, teachers, the media both mass media and citizen journalists, religious figures, and community figures. This proves that even when attempting to change long-held cultural beliefs, change is 112 possible through working together in a genuinely participatory way. One crucial lesson is the role that can be played by religious figures. In Bondowoso, religious figures are hugely respected and listened to. When they began advising against child marriage, the impact was immediately noticeable, with the rate of child marriage dramatically falling from 50 to 44 in just one year 2012 to 2013. As child marriage most severely affects the lives of children, it is clear that children themselves should be involved as not just recipients but as leaders. By educating young people on reproductive health, they are able to become peer educators Two teenagers film a video about child marriage in Bondowoso. 113 and share their knowledge with their friends and schoolmates. This is a very effective manner of changing young people’s attitudes, because they are more likely to listen to and believe their friends than their teachers or parents. The young people of Bondowoso were offered the chance to become reproductive health ambassadors, make their own anti-child marriage films and posters, and form community groups. Overall, changing long-held community beliefs cannot be done from above, led solely by the government. Bondowoso’s experience in successfully reducing child marriage rates supports this theory. Their active involvement of all sectors of society – from teachers and health workers to religious figures and the wives of government officials – shows that change is possible when all are genuinely involved and understand the reasons why change is necessary. Contact details Dr. Titik Erna Erawati Head of Family Health Section, Bondowoso District Health Office titikernaerawatiyahoo.com 114 Community Participation in Health Minimum Service Standards Planning in Jayapura, Papua Background Between 2009 and 2013, the budget allocated to public health services in Jayapura District dramatically decreased. While in 2009 the health budget represented 11 per cent of the government’s total budget, by 2013 it had fallen to just 5 per cent. The local government’s supposed commitment to health was not reflected in this allocation, and the district was not able to meet its Minimum Service Standards MSS targets as mandated by the national government. In 2013, Jayapura only achieved 36 of its MSS targets. A medical worker inspects the teeth of a patient in Jayapura. 115 Although MSS became a national requirement in 2008 through the Minister of Health Regulation No. 741 Menkes PerVII 2008, many health office staff do not understand the regulation and do not consider MSS important. Consequently, MSS is not used as a reference for developing new health programs; furthermore, it is not used to evaluate the government’s performance. In addition, the government of Jayapura does not involve community members in the development of health policies and programs. Many community members also do not understand their rights to quality health services, so demand for improvements is low. Innovation The low quality of health services in Jayapura is mainly caused by poor funding, inadequate understanding of MSS, and the absence of community participation. In order to improve Jayapura’s health services, Kinerja not only works with the government but with the community, building the capacity of local organizations to raise public awareness on people’s rights. Once the people understand their rights, they can demand quality public services. Recognizing that genuine partnerships between the government and the community are the key to implementing good governance in the public sector, Kinerja works closely with Jayapura District H ealth Office DEO. With Kinerja’s assistance, DEO staff improve their understanding of MSS and are able to apply the standards in their efforts to provide quality health services. Kinerja’s assistance in Jayapura covers three main stages: i identifying MSS achievements, ii 116 identifying gaps, and iii estimating the costs and developing scenarios to close gaps and meet targets through new policies and programs. In brief, Kinerja’s MSS program is carried out in the context of citizens’ health rights. Both government staff and community members are expected to understand that the government is responsible for providing standardized health services for the people and it has to prioritize it. Implementation Process Health service improvement programs are implemented by district technical team, whose membership consists of the decision makers from different relevant offices. The team advocates to the district administration to involve community District health office staff identify problems in health services at a workshop. 117 members in the process of integrating MSS in health into district planning and budgeting. Program implementation began with capacity building for local government staff, which was conducted through the following steps: 1. Raising awareness of relevant stakeholders decision makers, policy implementers, and community members on MSS in the health sector. 2. Reviewing and updating policies as needed. 3. Collecting data that would be used for calculating MSS achievements. 4. Analysing gaps. 5. Estimating budget and resources that are needed to close the gaps ‘costing’. 6. Public consultancy and oversight. 7. Integrating MSS targets and costs needed to achieve them into district health office’s and local government’s plans and budget. 8. Budget advocacy to decision makers to ensure the budget is signed off on. 9. Evaluating MSS achievements and collecting input for the next planning process. In Jayapura, public consultancy was carried out to discuss MSS costing results with broader stakeholders. The consultancy involved technical offices and other governing bodies since MSS achievements required inter-sectoral co-operation. The consultancy also provided room for community members to give their feedback and to support the district health office when it implemented the programs. 118 The Kinerja-supported multi-stakeholder forum MSF, as a community forum, was committed to monitoring health MSS achievements. MSS-related issues are discussed at MSF meetings both at the district and sub-district level so that citizens can better understand the issue. In addition, a number of radio talk shows on MSS have been carried out by local radio stations, Radio Kenambai Umbai and Radio Suara Kasih. These outdoor and indoor talk shows help to create momentum on standardized health service delivery. A citizen journalist forum called CYCLOPS and a forum of citizen documentary video makers, HILOI, also cover issues about standardized health services. Results and Impact Jayapura District has calculated the resources needed to achieve health MSS targets for four years – 2014 to 2017. The budget needed in 2014 was IDR 6,271,382,000 approximately US475,000, and it will increase to IDR 14,232,772,161 approximately US1 million for 2017. The budget increase is based on how to achieve the annual increases in targets. The Jayapura administration is committed to providing funds for to achieve MSS in the health sector in coming years. MSFs encourage governments to implement good governance. Government works with people to identify problems that health clinics face, discuss and address them. People should share responsibilities and have good understanding on how to be healthy. -Amos Soumilena MSF Coordinator, Jayapura. 119 Kinerja’s MSS program has successfully improved the awareness of government staff and community members on the importance and usefulness of MSS. It has also increased government staf f’s skills in assessing MSS achievements, estimating costs needed to achieve targets, and integrating standards into work plans and budgets. In 2014, the District Health Office allocated IDR 6.69 billion approximately US500,000 to fund programs to achieve MSS targets. The relationship between the District Health Office, the community health centers and the community is much stronger than it used to be. Both the government and the health centers involve MSFs as community representatives in their program planning and monitoring meetings. Being involved in the government program development, community members trust the local government more, and are more willing to support and to contribute to program implementation. For example, Kampung Yoboi in Sentani used village funds to provide financial support for four tuberculosis TB volunteers, who conduct TB education and observe treatment compliance. Previously, the volunteers only received a very small stipend form the health centers. Also in Sentani, an MSF called Forum Dobonsolo successfully advocated the sub-district administration to build TB posts in seven villages using Village Economic Empowerment funds. 120 A pregnant women undergoes a prenatal he k i o e of Ki erja’s part er li i s. With improved skills of MSS achievement analysis, health clinic staff are able to provide standardized health services. Monitoring and Evaluation With Kinerja’s help, the Jayapura District Health Office evaluated MSS implementation results in 2014 by involving MSFs. During the evaluation, government staff and community members assessed activity status, results, and challenges. This collaborative monitoring and evaluation will be conducted annually. If the activities are under target, the government and community seek solutions through broad consultation. Challenges The biggest challenge relating to implementing the MSS program in Jayapura was to maintain stakeholders’ commitment and develop appropriate skills. This problem was addressed through advocacy both formal and informal, workshops and meetings, especially with senior and mid-level staff. 121 Sustainability MSS program sustainability is highly reliant on the commitment of the head of the district health office. Based on Kinerja’s experiences, the head will commit to sustaining MSS if they have evidence about the program success. In Jayapura, Kinerja believes the MSS program is likely to be sustained since the costing results, including indicators of the MSS targets, and activities to achieve the MSS have been integrated into the five- year strategic plans of the district health office, as well as annual plans since 2014. Lessons Learned and Recommendations The lessons learnt from the benefits of community involvement in MSS include: 1. Awareness raising is vital for both service providers and service users. It means that people are able to give meaningful feedback to health service providers because they have been involved since the program’s inception and are aware of targets. 2. Programs that are based on the local context lead to increased levels of support. The MSS program in Jayapura not only took into account local values and beliefs, but was clearly based on local needs and evidence. This resulted in genuine support for the program from both government staff and community members, as they were able to understand why MSS is important for health services in their district. 122 3. Mainstream media, citizen journalism, and community forums such as MSFs can be powerful agents of change. Their position allows them to disseminate MSS-related information and to improve people’s knowledge on how MSS helps to fulfill their rights. In addition, partnerships of government, media, MSFs, health centers, and the district health office create joint opportunities for stakeholders to mobilize local government and community resources. 4. Implementing MSS in the health sector has led to a good appreciation for accurate data. Government decision makers are now aware that data is needed to develop strong work plans, create targets, and assess achievements. Learning about MSS has helped them to do this. Now, having seen benefits of MSS, the Jayapura district administration plans to adopt the program in other government technical offices. A number of recommendations can also be made on how to better incorporate MSS into health sector planning, budgeting, and monitoring: a. Community members should be involved in the full program cycle activity and budget planning, costing, MSS integration into budgets and planning, implementation, and monitoring and evaluation. Public participation is essential to ensuring that health services are delivered in line with MSS and that people’s rights to health services are fulfilled. Community participation is vital in all areas, including areas with high levels of political and social tension. 123 b. Intensive mentoring on MSS implementation, including for community members, should be continued to ensure local governments and health centers deliver services in line with national standards. It should be noted that Law no. 252009 confirms that people have the right to oversee public services. Their ability to do so must be strengthened. There are two important activities to ensure citizens are able to oversee service delivery i establishment of community forums, and 2 transparent information among local governments, community members, district health office, and health clinics.

c. Capacity building for district health offices is still

needed as some health offices do not understand how to synchronize their budgets so that they confirm to regulations from both Ministry of Home Affairs and Ministry of Health. This lack of understanding means that government staff cannot use their budgets innovatively to meet local needs and increase the human development index. Contact Person Amos Soumilena MSF Co-ordinator, Jayapura District 081248263822 124 Advocating for Improved Health Services through Citizen Journalism and Radio Talk Shows in Jayawijaya, Papua Background Despite the media’s strong influence in Papua, many local media outlets do not use their power to oversee public service or to advocate for improved health services. Many editors, especially in more remote areas such as Jayawijaya, do not believe health is an appealing topic that their audience wishes to read about. Even newspapers that do report on health issues tend to do so only irregularly and lack depth. This means that there is a lack of public oversight towards health services, which in turn has A citizen journalist interviews a religious and community leader in Papua. 125 led to a decrease in service quality. In many districts in Papua, health facilities are dirty deteriorated the health service delivery since there was no public supervision. In many districts, health clinics were dirty, medical equipment is often either broken or stolen, services are extremely slow, and health workers are often absent without reason. In Jayawijaya, with Radio Republik Indonesia RRI Wamena as the sole local media catering to audiences in the central highlands of Papua, the people have very limited sources of information on local issues. The other sources available to them tend to cover Papua as a whole, with minimal local news. Thus, many people are not aware of the situation in their own district, and are unable to compare the services they receive with other districts. Kinerja and its local partner NGO, the Indonesian Media Development Association Perhimpunan Pengembangan Media Nusantara – PPMN, are assisting RRI Wamena to run campaigns that advocate for improvements in health services. The programs, which have been piloted in three Kinerja- supported areas in Jayawijaya – Hom-hom, Hubikosi and Musatfak – include indoor and outdoor radio talkshows and public service announcements. In addition to working with the local media mainstream, Kinerja is also training citizen journalists to demand better quality health services. Innovation A lack of news and poor access to media sources is one of the major reasons behind why health services remain of poor quality in Jayawijaya. Without oversight from the public and the